Laparoscopic surgery for benign and malign diseases of the digestive system: Indications, limitations, and evidence

A retrospective study comparing minimally invasive versus open surgical resection of small intestinal neuroendocrine neoplasms at a tertiary referral center

INTRODUCTION

Neuroendocrine neoplasms (SI-NEN) are the commonest malignancies of the small intestine. Traditionally, surgical treatment for SI-NEN has been open surgery.

PURPOSE

The purpose of this study was to compare minimally invasive surgery (MIS) with the traditional open surgery approach for treating SI-NEN in a Swedish population.

METHODS

Patients with histopathological confirmed SI-NEN who underwent open surgery or MIS resection within 2009-2021 were extracted from the hospital's medical records.

RESULTS

65 patients were included in this study, with 35 (54 %) undergoing MIS and 30 (46 %) undergoing open surgery. We found no statistically significant difference (p = 0.173) in the frequency of R0 resections (MIS group n = 34 (97 %), open surgery group n = 26 (87 %)). Nor was there a significant difference (p = 0.101) when comparing the median number of resected lymph nodes (MIS group n = 13.5, open surgery group n = 10). A post-operative paralytic ileus was more often reported (p = 0.052) in the MIS group (n = 9, 26 %) compared to the open surgery group (n = 2, 7 %). In light of this, the days of hospital stay did not differ significantly (MIS group median = 6, IQR (5-8), open surgery group median = 6, IQR (5-9)). The Kaplan-Meier analysis did not reveal differences concerning cancer-related deaths (p = 0.109).

CONCLUSION

The results from this study support that a MIS approach for the treatment of SI-NEN may not be inferior to open surgery. The higher number of resected lymph nodes and R0 resections may even speak in favor for a MIS approach. More studies with a longer time of observation are needed to further support this conclusion.

Effect of laparoscopic versus open surgery on postoperative wound complications in patients with low rectal cancer: A meta-analysis

This meta-analysis was conducted to evaluate the effect of microinvasive and open operations on postoperative wound complications in low rectal carcinoma patients. Research on limited English has been conducted systematically in PubMed, Embase, Cochrane Library and Web of Science. The date up to the search was in August 2023. Following review of the classification and exclusion criteria for this research and the evaluation of its quality in the literature, there were a total of 266 related papers, which were reviewed for inclusion in the period from 2004 to 2017. A total of 1774 cases of low rectal cancer were enrolled. Of these 913 cases, the laparoscopic operation was performed on 913 cases, while 861 cases were operated on low rectal carcinoma. The overall sample was between 10 and 482. Five trials described the efficacy of laparoscopy have lower risk than open on postoperative wound infection in patients with low rectal cancer (OR, 0.72;95 % CI, 0.48,1.09 p = 0.12). Three studies results showed that the anastomotic leak was not significantly different between open and laparoscopy (OR, 0.86; 95% CI, 0.58,1.26 p = 0.44). Six surgical trials in low rectal cancer patients reported haemorrhage, and five cases of surgical time were reported, with laparoscopy having fewer bleeding compared with open surgery (MD, -188.89; 95% CI, -341.27, -36.51 p = 0.02). Compared with laparoscopy, the operation time was shorter for the open operation (MD, 33.06; 95% CI, 30.56, 35.57 p < 0.0001). Overall, there is no significant difference between laparoscopy and open surgery in terms of incidence of infection and anastomosis leak. However, the rate of haemorrhage in laparoscopy is lower，and operation time in open surgery is lower.

Innovation in gastrointestinal surgery: the evolution of minimally invasive surgery-a narrative review

Background

Minimally invasive (MI) surgery has revolutionised surgery, becoming the standard of care in many countries around the globe. Observed benefits over traditional open surgery include reduced pain, shorter hospital stay, and decreased recovery time. Gastrointestinal surgery in particular was an early adaptor to both laparoscopic and robotic surgery. Within this review, we provide a comprehensive overview of the evolution of minimally invasive gastrointestinal surgery and a critical outlook on the evidence surrounding its effectiveness and safety.

Methods

A literature review was conducted to identify relevant articles for the topic of this review. The literature search was performed using Medical Subject Heading terms on PubMed. The methodology for evidence synthesis was in line with the four steps for narrative reviews outlined in current literature. The key words used were minimally invasive, robotic, laparoscopic colorectal, colon, rectal surgery.

Conclusion

The introduction of minimally surgery has revolutionised patient care. Despite the evidence supporting this technique in gastrointestinal surgery, several controversies remain. Here we discuss some of them; the lack of high level evidence regarding the oncological outcomes of TaTME and lack of supporting evidence for robotic colorectalrectal surgery and upper GI surgery. These controversies open pathways for future research opportunities with RCTs focusing on comparing robotic to laparoscopic with different primary outcomes including ergonomics and surgeon comfort.

Trends of sphincter-preserving surgeries for low lying rectal cancer: A 20-year experience in China

Background

Over the last 2 decades, patients with low rectal cancer have had better outcomes from improvements in surgical techniques in sphincter preservation. We aimed to quantify the trends in sphincter-preserving surgeries for low rectal cancer over 20 years in a top tertiary hospital in China.

Methods

Between 1999 and 2021, a cohort of patients with primary malignant rectal tumor ≤5cm from the anal verge and who received elective surgeries at Changhai Hospital, Shanghai, China, was identified. Data were extracted from electronic medical records. A Joinpoint Regression Model was used to analyze trends in surgical procedures by average annual percentage change (AAPC). Adjusted Cox proportional hazards regression model was used to assess overall survival.

Results

Among a total of 4,172 patients during the study period, 3,111 (74.6%) underwent a sphincter-preserving surgery and 1,061 (25.4%) received APR. Sphincter-preserving surgery increased 3.6% per year (95%CI, 2.3-4.9). Low anterior resection was the most performed procedure (86.3%) and maintained a steady trend, while intersphincteric resection increased 49.4% annually (95%CI, 19.5-86.7) after initiation. Laparoscopic techniques increased 15.1% per year (95%CI, 8.4-43.4) after initiation. Sphincter-preserving surgery increased annually for tumors ≤2cm, 2-≤3cm and 3-≤4cm from the anal verge (AAPC 7.1, 4.5-9.8; 4.7, 3.1-6.3; 2.7, 1.7-3.6, respectively). Furthermore, patients with sphincter-preserving surgery had a better overall survival than abdominoperineal resection (APR) patients (adjusted HR 0.78, 95% CI, 0.65-0.93, p=.01).

Conclusions

Utilization of sphincter-preserving surgeries increased significantly over the last 20 years. Patients with low rectal cancer who underwent sphincter preservation had better survival than similar patients who underwent APR.

Laparoscopic Training for Gastrointestinal Surgery Using Japanese Traditional Papercraft Origami

PURPOSE

The aim of this study is to show the experience and results of laparoscopic training using origami, a Japanese traditional papercraft, and to discuss its usefulness in gastrointestinal surgery.

MATERIALS AND METHODS

A laparoscopic training dry box was used. An origami paper crane was folded using laparoscopic instruments. The time to complete the origami crane was measured.

RESULTS

Two trainees participated in this study; the total number of origami cranes folded by these trainees was 2000 and 700, respectively. The learning curve gradually improved. According to our experience, this training strengthened mental faculties and was associated with the improvement of hand-eye and left-right coordination, reduction of tremor, acquisition of delicate technique, the ability to distinguish subtle differences in color, ability to respond to trouble.

CONCLUSIONS

Laparoscopic training for gastrointestinal surgery using origami may have the potential to improve the technical skills in laparoscopic surgery.

A retrospective multicentre study on the evaluation of perioperative outcomes of single-port robotic cholecystectomy comparing the Xi and SP versions of the da Vinci robotic surgical system

BACKGROUND

Single-incision robotic cholecystectomy (SIRC) is widely performed with both the da Vinci Xi system (Xi) and the da Vinci SP system (SP). But there are limited numbers of studies comparing these platforms.

METHODS

Patients who underwent SIRC between 2019 and 2020 were enrolled. Patient demographics, intraoperative factors, postoperative complications, postoperative pain were compared using a one-to-one propensity score matching (PSM).

RESULTS

Overall, 258 patients underwent SIRC with Xi and 72 with SP. After PSM, there were significant differences between the Xi and SP in operation time at console and numeric rating scale for postoperative pain, but no difference in total operation time and postoperative complications. The SP group showed more estimated blood loss.

CONCLUSIONS

Despite the statistical difference, clinical benefit was not significant. Both platforms can be safe and feasible to perform SIRC, but further investigation including the surgeon's workload and ergonomics is needed as a prospective study.

Endoscopically assisted implant removal of a symphyseal pelvic plate - A case report

Introduction

The approach-related morbidity rate in the care of pelvic fractures is still high. Endoscopic procedures are known to significantly reduce access-related complications. Recently, a new endoscopically assisted implantation technique for plate osteosynthesis on the anterior pelvic ring has been described as the “Endoscopic Approach to the Symphysis”.

Case report

We present a case of a 29-year old male with a pelvic injury (AO type 61B2.3a) initially treated with a supraacetabular external fixator. After one week the definitive stabilization was performed by an endoscopically assisted symphyseal plating as well as a percutaneous iliosacral screw on the right side. One year after primary surgery, we performed an endoscopically assisted removal of the symphyseal plate using standard laparoscopic instruments.

Results

We demonstrate the feasibility of an endoscopically assisted implant removal at the anterior pelvic ring. No complications occurred during the procedure. The patient was discharged after a regular time of surveillance and with an adequate decline of pain.

Discussion

While we were able to show that the endoscopically assisted implantation as well as the removal of a plate osteosynthesis on the anterior pelvic ring is possible, there is still further research necessary, especially regarding the development of specific endoscopic instruments. This should enable operating times similar to the standard open procedures.

Dual trocar laparoscopy improves reduced-port surgery of the distal pancreas

BACKGROUND

The technical feasibility of transumbilical single-incision surgery (SIL) for pancreatic resections has been demonstrated. However, this technique is hampered by the limited degrees of freedom for instrument handling. Dual-incision laparoscopy (DIL) with an additional trocar may simplify dissection and allow drainage.

MATERIAL AND METHODS

Between December 2009 and May 2017, 21 patients were treated with SIL (12/2009 to 01/2014) or DIL (02/2014 to 05/2017) pancreatic resection. All data were collected in a database and retrospectively analysed.

RESULTS

Demographic parameters of the patients did not differ significantly in the DIL or the SIL group. No conversion to open surgery was required. No intraoperative complication occurred in either group. The surgical difficulty score was significantly higher in the SIL group (4.4 ± 1.56 vs 2.18 ± 1.95; p = .006). Postoperative serum amylase levels were higher (101.9 U/l ± 50.11 vs 48.91 U/l ± 35.20; p = .01) and return to normal levels (6.4 ± 9.66 days vs 2.09 ± 1.98 days; p = .045) was later in the SIL group. Three complications requiring radiological or surgical intervention were witnessed in the SIL group and one complication in the DIL group (p = .42).

CONCLUSION

DIL surgery is a safe and feasible alternative to SIL surgery, facilitating key steps of distal pancreatic tail resection.

Laparoscopic Versus Open Re-operations Within 30 Days After Lower Gastrointestinal Tract Surgery: a Retrospective Comparative Study

BACKGROUND

Re-operations within 30 days after lower gastrointestinal tract surgery are associated to high morbidity and mortality. Laparoscopic approach has been reported as feasible and safe in selected patients, but comparative data to laparotomy are scarce. The aim of this study was to review our experience in laparoscopic re-operations and compare it to laparotomy.

METHODS

From January 2012 to December 2016, patients undergoing a re-operation within one month after lower gastrointestinal tract surgery were included and divided into laparoscopy and laparotomy groups. The primary endpoint was successful re-operation, defined as recovery without any of the following: conversion to laparotomy, need of further invasive treatments or death. Secondary outcomes were the length of hospital stay and 30-day morbidity and mortality. Demographic, clinical and surgical characteristics were collected and analyzed.

RESULTS

Out of 114 patients who underwent a re-operation, 71 met the inclusion criteria. Thirty (42%) patients underwent laparoscopy and 41 (58%) laparotomy. Thirty (42%) patients were male and median age was 72.0 years-old. The initial operation was elective in 24 (34%) patients, and 50% of the initial operations were colorectal resections in both groups. Multivariate analyses showed that type of approach did not affect the re-operation success rate. Laparotomy was an independent predictor of prolonged hospital stay (OR 3.582, 95%CI 1.191-10.776, p = 0.023) and mortality (OR 13.123, 95%CI 1.301-131.579, p = 0.029).

CONCLUSIONS

Re-operations within 30 days after lower gastrointestinal tract surgery may be safe in selected patients, as effective as laparotomy, and associated with shorter hospital stay and lower mortality rates.

Liver Parenchyma Transection-First Approach for Laparoscopic Left Hemihepatectomy: A Propensity Score Matching Analysis

BACKGROUND

Laparoscopic major liver resection, such as laparoscopic left hemihepatectomy (LLH), is still perceived as a complicated procedure due to technical difficulties and slow learning curve. The study introduced an optimized procedure using the liver parenchyma transection-first approach and investigated its advantages on surgical outcomes by comparison with the conventional hilar dissection approach for LLH.

METHODS

Between January 2015 and May 2019, 96 patients who underwent laparoscopic left hemihepatectomy for hepatocellular carcinoma (HCC) were enrolled in the study. Among these, 41 patients underwent the liver parenchyma transection-first approach (LP-first group) and the other 55 underwent the conventional hilar dissection approach (conventional group). A 1:1 propensity score matching (PSM) was performed to compare the perioperative and long-term oncological outcomes of the two groups.

RESULTS

After 1:1 PSM, 37 patients in each group were selected for further analysis. The LP-first group was associated with shorter median operative time (210 vs 235 min, P = 0.035) and less blood loss (200 vs 300 mL, P = 0.410). In addition, no statistical differences were found in overall complications between the two groups (8.1% vs 24.3%, P = 0.058). There were no significant differences between the two groups in terms of 1-year and 3-year disease-free survival (DFS, P = 0.608) and overall survival (OS, P = 0.414).

CONCLUSION

The prior liver parenchyma approach for LLH is safe and reproducible in selected patients, which showed improved perioperative outcomes and comparable long-term oncological outcomes compared with the conventional approach.

Evaluation of the learning curve for laparoscopic pancreatoduodenectomy by CUSUM analyses. Cohort study

INTRODUCTION

Laparoscopic pancreatoduodenectomy (LPD) remains an extremely demanding surgery. The purpose of this study was to describe the learning curve required for its safe implementation.

METHODS

Fifty consecutive patients undergoing LPD were retrospectively reviewed. The learning curve was clustered into 4 groups: A, B and C (initial phase, n = 10 each) and D (consolidation phase, n = 20). Cumulative Sum (CUSUM) analysis was applied to operative time, conversion rate and severe postoperative complications.

RESULTS

No significant differences were observed among groups and phases concerning specific and general postoperative complications, oncological outcomes or mortality. The conversion rate significantly reduced from 90% (9) in Group A to 40% (4) in Group C (p < 0.01). Operative time was longer in the consolidation phase (median of 506 vs 437 min, p < 0.01). Conversely, hospital stays were shorter during the consolidation phase (8 vs 15 days, p < 0.01). CUSUM analysis identified 20-25cases as being enough to complete the learning curve if operative time and severe complications are analysed, while 40 cases would be needed for considering the conversion rate.

CONCLUSIONS

The learning curve in LPD can be completed after 20-25 procedures. This information will help to design programmes for introducing new surgeons to this technique.

Laparoscopic Versus Open Liver Resection for Benign Tumors and Lesions: A Case Matched Study with Propensity Score Matching

Background and Aim: In recent years, minimally invasive surgical approaches have gained an increasingly important role in hepatobiliary surgery. The aim of this study was to investigate the safety and potential benefits of laparoscopic liver resection (LLR) compared with open liver resection (OLR) for benign liver tumors and lesions. Patients and Methods: Between January 2009 and December 2017, 182 patients underwent liver resection for benign liver tumors and lesions at our center. After exclusion of 15 patients, the remaining 167 patients were divided into LLR group (n = 54) and OLR group (n = 113) and were compared with regard to perioperative outcomes. To overcome selection bias, a 1:1 propensity score matching (PSM) was performed. In addition, patients undergoing major hepatectomy were divided into major-LLR and major-OLR groups and perioperative outcomes evaluated. Results: After PSM, 35 patients were included in the OLR group and 35 patients in the LLR group. The LLR group had a significantly shorter median intensive care unit (ICU) stay (LLR: 1 [0-4] days; OLR: 1 [0-3] days; P = .009) and median hospital stay (length of stay [LOS]) (LLR: 7 [4-14] days; OLR: 10 [5-16] days; P < .001). There were no statistically significant differences in postoperative complications graded as Clavien-Dindo ≥III (LLR: 11.4%; OLR: 2.9%; P = .375) in both groups. Postoperative 90-day mortality was 0% in both groups. When comparing major-LLR (n = 8) with major-OLR (n = 59), patients in the major-LLR group had a significantly longer median operation time (major-LLR: 403 [240-501] minutes; major-OLR: 221.5 [111-529] minutes; P < .001), but a significantly shorter median LOS (major-LLR: 7 [5-14] days; major-OLR: 9 [7-129] days; P = .013). The rate of major complications (Dindo Classification ≥III) for major-LLR was 0% and for major-OLR it was 16.9% (P = .207). Conclusion: Our case-matched study demonstrates shorter ICU and hospital stay using laparoscopic techniques while maintaining high-quality perioperative outcomes. Based on our findings, we suggest preferring the LLR over OLR for benign liver tumors and lesions regardless of the resection extent.

The long-term clinical outcomes of robotic gastrectomy for gastric cancer: a large-scale single institutional retrospective study

BACKGROUNDS AND PURPOSE

Robotic surgery has been applied in gastric carcinoma over a decade. Although a series of studies were performed to investigate the short-term outcomes of robot-assisted gastrectomy, few papers were in view of long-term outcomes. The current study was aimed to explore the oncological outcomes of robotic gastrectomy for gastric cancer patients.

METHODS

A total of 606 gastric cancer patients who underwent robot-assisted gastrectomy during March 2010 through March 2017, were enrolled in this research. The clinicopathologic characteristics, surgical procedures along with follow-up information and prognostic factors were recorded in detail. The disease-free survival and overall survival rates were tested by Kaplan-Meier analysis.

RESULTS

All the patients underwent the robotic surgery including 15 proximal gastrectomies, 403 distal gastrectomies, 169 total gastrectomies and 19 remnant gastrectomies. Fifiy-six (9.24%) patients were lost in the follow-up process (3-87 months, a media of 42 months). There were 119 recurrences observed, including 55 local recurrences, 51 peritoneal metastasis and 13 distant metastasis. The 3-year disease-free survival and overall survival were 73.60% and 74.24%, while the 5-year disease-free survivorship and overall survival rates were 68.73% and 69.33%. The 5-year overall survival rates grouped based on TNM stage were 96.58% for IA, 88.16% for IB, 87.03% for IIA, 80.62% fo IIB, 58.50% for IIIA, 48.62% for IIIB, 45.32% for IIIC and 17.03% for IV.

CONCLUSION

Robot-assisted gastrectomy is a valuable procedure for gastric cancer patients. Beside its feasibility and safety, it reveals an acceptable long-term clinical outcome.

Successful Laparoscopy-Assisted Resection of the Descending Colon in a Patient with Multiple Large Renal Cysts and Stricture of the Colon due to Ischemic Colitis

Large pathological structures in the abdominal cavity curb the application of laparoscopic surgery. This case report describes a successful laparoscopy-assisted colectomy for benign colon disease in a patient with multiple large renal cysts. An 82-year-old man was referred to our department for treatment of stenosis of descending colon secondary to ischemic colitis. An abdominal computed tomography revealed multiple large renal cysts occupying a large proportion of the peritoneal cavity. To minimize the postoperative recovery period, laparoscopic surgery was planned despite the renal cysts. After inserting access ports, the walls of the several renal cysts were fenestrated with an electronic scalpel and the serous fluid was aspirated to enable continuation of the laparoscopic colectomy. The left colon was mobilized and extracted through an incision at the umbilicus, and the affected part of the colon was resected safely. The patient's postoperative course was uneventful, and the present case suggests that laparoscopy-assisted colectomy can be performed safely even in patients with multiple large renal cysts.

Impact of the preoperative use of synbiotics in colorectal cancer patients: A prospective, randomized, double-blind, placebo-controlled study

OBJECTIVES

Gastrointestinal microflora is involved in the development and regulation of the immune response. Non-pathogenic bacteria are important to prevent the development and subsequent invasion of enteropathogenic bacteria. Surgical trauma and intestinal preparation can disrupt the intestinal microbiota balance. Modulating the microbiota in the preoperative period in patients with colorectal cancer may have an effect on the occurrence of postoperative complications. The aim of this study was to assess the effect of preoperative synbiotic administration in patients with colorectal cancer subjected to colorectal resection.

METHODS

This was a prospective, randomized, double-blind, placebo-controlled study of 73 patients with colorectal cancer. Eight days before surgery, patients were randomized to receive either synbiotics (Simbioflora, Farmoquimica, São Paulo, Brazi) or placebo (maltodextrin). The envelopes were identical and labeled A or B. All patients underwent nutritional assessment and measurements of C-reactive protein (CRP), interleukin (IL)-6, serum albumin, and transferrin. Patients were given a diluted envelope in 100 mL of water twice daily for 7 d. The occurrence of infectious or non-infectious complications, time of antibiotic use, duration of hospitalization, and occurrence of deaths were recorded for 30 d postoperatively.

RESULTS

Mean age, demographic data, and tumor staging were similar between the groups at baseline. After 7 d of synbiotic intake, there were significant reductions in IL-6 levels (163.2 ± 19.5 versus 138.8 ± 12.5, P < 0.001) and CRP (10 ± 5.2 versus 7.17 ± 3.2, P < 0.001), whereas the control group did not present significant changes I IL-6 levels (154.2 ± 18.3 versus 160.9 ± 18.6, NS) or CRP (10.6 ± 6.18 versus 10.4 ± 6.1, NS). Serum albumin and transferrin did not show significant changes. Postoperative infectious complications occurred in 2.8% of patients in the synbiotic group and in 18.9% of the control group (P = 0.02). The mean antibiotic usage time was 1.42 ± 0.5 d in the synbiotic group and 3.74 ± 4.3 d in the control group (P < 0.001). The mean hospital length of stay was 3 ± 1 d in the synbiotic group and 4 ± 18 in the control group (P < 0.001). Three deaths were reported in the control group and none in the synbiotic group (P = 0.115).

CONCLUSIONS

The use of synbiotics for 7 d preoperatively in patients with colorectal cancer attenuates the inflammatory state and is associated with reductions in morbidity, hospital length of stay, and use of antibiotics.

EASY (endoscopic approach to the symphysis): a new minimally invasive approach for the plate osteosynthesis of the symphysis and the anterior pelvic ring-a cadaver study and first clinical results

BACKGROUND

Minimally invasive surgical approaches to reduce approach-associated morbidity are an interdisciplinary goal in surgery. In principle, the endoscopic approach for the extraperitoneal repair of groin hernias is the minimally invasive variant of the modified Stoppa-approach, which is used for the treatment of pelvic ring injuries in traumatology.

METHOD

Anatomical feasibility study regarding the plate osteosynthesis of the anterior pelvic ring via a minimally invasive variant of the modified Stoppa-approach.

RESULTS

We present the minimally invasive variant of the modified Stoppa-approach in a human cadaver step by step, both photographically and radiologically. Feasibility of the plate osteosynthesis of the symphysis is presented in a patient with open book injury via the minimally invasive approach using standard laparoscopic instruments.

CONCLUSION

The plate osteosynthesis of the anterior pelvic ring via the minimally invasive variant of the modified Stoppa-approach is feasible with existing standard laparoscopic instruments.

[Early outcomes of open, laparoscopic and robot-assisted pancreatoduodenectomy]

AIM

To study immediate results of open, laparoscopic and robot-assisted pancreatoduodenectomy for malignancies.

MATERIAL AND METHODS

There were 158 patients with cancer of biliopancreatoduodenal area. Open procedures were performed in 118 cases, laparoscopic in 17, robot-assisted pancreatoduodenectomy - in 23.

RESULTS

After 'standard' pancreatoduodenectomy 31 (62.0%) complications were registered, after laparoscopic - 12 (24.0%) and aWfter robot-assisted surgery - 7 (14.0%) complications. Relationship between probability of complications was absent (correlation coefficient 0.10491), however, significant differences in incidence of complications after various surgical approaches were observed (c²=6.8832; df=0.9679; p<0.05).

CONCLUSION

Laparoscopic and robot-assisted pancreatoduodenectomy was not followed by advanced early postoperative morbidity. Moreover, minimally invasive approach was associated with improved outcomes.

Laparoscopic distal resection of the pancreas. Can be all resections of body and tail of the pancreas called the same?

Introduction

Distal resection of the pancreas is a routine procedure in high-volume centres. However, the volume of this procedure can vary. This variation plays a very important role in laparoscopic approach of pancreatic surgery and can be a real challenge if the anatomical situation is underestimated.

Aim of the study

To present our experience in minimally invasive treatment of the pancreatic tumours and to discuss different approaches to different anatomical situations.

Material and methods

We performed a retrospective analysis of patients, who underwent laparoscopic pancreas resection for pancreatic cancer in our hospital since 2014 to 2016 February. According to extension of operation, patients were divided into two groups: distal pancreatectomy and left hemipancreatectomy for cases that required preparation of the portal vein. Demographic characteristics, and operative and postoperative data were compared between both groups.

Results

Out of 16 patients, distal pancreatectomy was performed for 7 (43.8%) and left hemipancreatectomy for 9 (56.2%) patients. For 1 (14.3%) laparoscopic distal pancreatectomy and for 2 (22.2%) laparoscopic left hemipancreatectomy patients surgical conversion to laparotomy was performed. The average operation time was 205 (195–245) min for distal pancreatectomy and 412.5 (280–520) min for left hemipancreatectomy group (p = 0.001), blood loss 125 (20–250) ml and 250 (50–1800) ml accordingly (p = 0.138). Totally postoperative fistula occurred in 7 (43.8%) cases; out of them, 5 (71.4%) patients were from the left hemipancreatectomy group.

Conclusions

Laparoscopic left hemipancreatectomy is more complicated than distal pancreatectomy. Extension and technique selection of distal resection of the pancreas depends on the Yonsei criteria and tumour relation to the portal vein.

Pancreatic resection in the era of laparoscopy: State of Art. A systematic review

BACKGROUND

Innovation in surgical devices and improvement in laparoscopic skills have gradually led to achieve more challenging surgical procedures. Among these demanding interventions is the pancreatic surgery that is seen as intraoperatively risky and with high postoperative morbi-mortality rate. In order to understand the complexity of laparoscopic pancreatic surgery, we performed a systematic review of literature.

DATA SOURCE

A systematic review of literature was performed regarding laparoscopic pancreatic resection.

RESULTS

Laparoscopic approach in pancreas resections has been extensively reported as safe and feasible regarding pancreaticoduodenectomy, distal pancreatectomy and pancreatic enucleation. Compared to open approach, no benefit in morbi-mortality has been demonstrated (except for laparoscopic distal pancreatectomy) and no controlled randomized trials have been reported.

CONCLUSIONS

Laparoscopic approach is not workable in all patients and patient selection is not standardized. Additionally, most optimistic reports considering laparoscopic approach are produced by tertiary centres. Currently, two tasks should be accomplished 1°) standardization of the laparoscopic pancreatic procedures 2°) comparative trials to assess endpoint benefits of laparoscopic pancreatic resection compared with open procedures.

An Improved Surgical Technique for Pure Laparoscopic Left Hemihepatectomy: Ten Years Experience in a Tertiary Center

Background: This study details our experience with an improved surgical technique involving the hepatic pedicle during laparoscopic left hemihepatectomy (LLH).

Methods: We describe an improved laparoscopic technique to extraparenchymally divide the left hepatic pedicle. A retrospective analysis of all of the patients who underwent laparoscopic liver procedures between 2002 and 2012 was conducted. The patients were divided into two groups, an early LLH group (ELLH group) and a recent LLH group (RLLH group), based on the surgical approach used for the left hepatic pedicle.

Results: A total of 72 cases of LLH (26 ELLH and 46 RLLH) were identified. The RLLH group exhibited a shorter median operative time, median length of hospital stay, and lower median blood loss compared to the ELLH group (182, 162.5–223.7 versus 232.5, 200–357.5 minutes, P < .01; 5, 4.2–7 versus 7, 6–8.7 days, P < .05; 150, 100–257.5 versus 300, 200–337.5 mL, P < .05, respectively). No perioperative mortality was observed.

Conclusions: This study confirms that our improved surgical technique for LLH is practical, safe, and effective. The main advantage of this method compared to other techniques is the possibility of attaining rapid and precise control of vascular inflow, thus facilitating LLH.

Laparoscopic pancreatic resection-a review

Contrary to many other gastrointestinal operations, minimal access approaches in pancreatic surgery have gained ground slowly. Laparoscopic distal pancreatectomy has gained wide acceptance. It is associated with reduced blood loss and shorter duration of stay (DOS) while oncologic results and morbidity are similar to open surgery. In recent years the number of laparoscopic pancreatoduodenectomies has also increased. While oncological outcome seems comparable to the open approach, operative times are longer while DOS and blood loss are reduced. One added advantage of the laparoscopic approach to pancreatic cancer seems to be that adjuvant treatment can start earlier. Minimal access total pancreatectomy, only reported in small numbers (mostly robot assisted), has also been shown to be feasible and safe. Enucleation (EN) of small pancreatic lesions is the most common tissue sparing resection. Although no reconstruction is necessary, the risk of pancreatic fistula is high, related to excision margins equal or smaller than 2 mm to the main pancreatic duct. Compared to the open approach, laparoscopic EN has shown comparable results in terms of morbidity, pancreatic function and fistula rate, with shorter operation times and faster recovery. Experience in robot assisted pancreatic surgery is increasing. However reports are still small in numbers, lacking randomization and mostly limited to dedicated centers. The learning curve for minimal access pancreatic surgery is steep. Low patient volume leads to longer DOS, higher costs and negatively impacts outcome.

Impact of Type of Surgery on Survival Outcome in Patients With Early Gallbladder Cancer in the Era of Minimally Invasive Surgery: Oncologic Safety of Laparoscopic Surgery

Laparoscopic surgery has been widely accepted as a feasible and safe treatment modality in many cancers of the gastrointestinal tract. However, most guidelines on gallbladder cancer (GBC) regard laparoscopic surgery as a contraindication, even for early GBC. This study aims to evaluate and compare recent surgical outcomes of laparoscopic and open surgery for T1(a,b) GBC and to determine the optimal surgical strategy for T1 GBC.The study enrolled 197 patients with histopathologically proven T1 GBC and no history of other cancers who underwent surgery from 2000 to 2014 at 3 major tertiary referral hospitals with specialized biliary-pancreas pathologists and optimal pathologic handling protocols. Median follow-up was 56 months. The effects of depth of invasion and type of surgery on disease-specific survival and recurrence patterns were investigated.Of the 197 patients, 116 (58.9%) underwent simple cholecystectomy, including 31 (15.7%) who underwent open cholecystectomy and 85 (43.1%) laparoscopic cholecystectomy. The remaining 81 (41.1%) patients underwent extended cholecystectomy. Five-year disease-specific survival rates were similar in patients who underwent simple and extended cholecystectomy (96.7% vs 100%, P = 0.483), as well as being similar in patients in the simple cholecystectomy group who underwent open and laparoscopic cholecystectomy (100% vs 97.6%, P = 0.543). Type of surgery had no effect on recurrence patterns.Laparoscopic cholecystectomy for T1 gallbladder cancer can provide similar survival outcomes compared to open surgery. Considering less blood loss and shorter hospital stay with better cosmetic outcome, laparoscopic cholecystectomy can be justified as a standard treatment for T1b as well as T1a gallbladder cancer when done by well-experienced surgeons based on exact pathologic diagnosis.

da Vinci and Open Radical Prostatectomy: Comparison of Clinical Outcomes and Analysis of Insurance Costs

PURPOSE

To assess clinical outcomes and reimbursement costs of open and robotic-assisted radical prostatectomies in Germany.

METHODS

Perioperative data of 499 open (2003-2006) and 932 (2008-2010) robotic-assisted radical prostatectomies as well as longitudinal reimbursement costs of an anonymized health insurance research database from Germany containing data of patients who underwent robotic-assisted or open radical prostatectomy were retrospectively analysed in a single-centre study.

RESULTS

Significantly better outcomes after robotic-assisted vs. open prostatectomy were observed in regards to positive surgical margins (13.3 vs. 22.4%; p < 0.0001), intraoperative transfusions (0.1 vs. 2.6%; p < 0.0001), hospitalization (8.7 vs. 15.2 days; p < 0.0001) and duration of catheter (6.6 vs. 12.8 days; p < 0.0001). Operating time was significantly longer with robotic-assisted radical prostatectomy when compared to open surgery (184.4 vs. 128.0 min; p < 0.0001), while intraoperative complications showed a similar occurrence between both groups. Significant fewer postoperative complications were observed after robotic-assisted radical prostatectomy (26.5 vs. 42.5%; p < 0.0001) and rate of re-admission was lower for the robotic patients (13.6 vs. 19.4%; p = 0.0050). While insurance costs were higher in the 2 years before radical prostatectomy for the patients who underwent a robotic procedure (4,241.60 vs. 3,410.23 €; p = 0.202), additive costs of care of the year of surgery plus the 2 following years were less for the robotic cohort when compared to the costs incurred by the open group (21,673.71 vs. 24,512.37 €; p = 0.1676).

CONCLUSIONS

The observed clinical advantages of robotic-assisted radical prostatectomy seem to result in reduced health insurance cost postoperatively when compared to open surgery. This should be taken into consideration regarding reimbursement and implementation of a clinically superior method.